Lung cancer and Melanoma Flashcards
State the 4 most common symptoms of lung cancer
- Persistent unexplained cough lasting more than 3 weeks
- Haemoptysis
- SOB
- Weight loss
State some investigations for suspected lung cancer
Initial:
- Bloods
- CXR
Further:
- Biopsy for histology (CT-guided, bronchoscopy or thoracoscopy if pleural effusion)
- Staging CT
- Evaluate fitness and lung function tests (helps predict whether surgery will leave patient breathless after)
Followed by MDT discussion
State some bloods to do for suspected lung cancer
Calcium is VERY important - most common sign found in lung cancer
- FBC
- U&Es
- Calcium (most common sign)
- LFTs (check for liver mets)
- INR (check for liver mets)
State some histology options for biopsy in lung cancer
Choose based on whether the tumour is central, peripheral or peri-bronchial/para-tracheal
- Sputum cytology
- Bronchoscopy
- EBUS-TBNA (specific type of bronchoscopy)
- CT guided lung biopsy
State some investigations for malignant pleural effusion
- Bloods (same as standard suspected lung cancer)
- US guided aspirate and cytology/microbiology
If cytology from US guided aspirate if negative, need to do a medical thoracoscopy
Pleural effusion cancer cannot be cured
State an incidental nodule and why is it significant in lung cancer
“blob” in the lung >5mm
Significant as it may represent early cancer - if > 20mm then 50% chance of developing cancer
State how MSCC (metastatic spinal cord compression) can present and how to manage
Presentation:
- Upper motor neurone signs
- Back pain (progressive, unremitting, worse on straining)
- Localised tenderness over affected area
- Urinary retention / constipation
- Sensory loss in saddle area
Management:
- Urgent MRI with discussion with spina surgeon and oncologist
- Urinary catherisation
- High dose steroids (IV or PO) e.g. oral Dexamethasone 16mg
- Radiotherapy / surgical decompression (depending on prognosis)
State how manage hypercalcaemia in lung cancer
- IV fluids for around 48 hours (dilute calcium)
- Pamidronate infusion over 30-60 mins (drives Ca back into cells) (Zoledronate in breast or prostate cancer)
This will control calicum for around 6 weeks - in time to manage underlying condition
State how SVC obstruction can present, suggested imaging and how to manage (acute and long term)
Presentation:
- Localised oedema of the face and upper extremities
dyspnoea
- Dyspnoea
- Cough
- Facial plethora
- Distended neck/chest veins
- Hoarseness of voice
Suggested imaging:
- Chest x-ray
- CT scan (staging CT helpful)
Acute management:
- Sit patient upright
- Oxygen
- Analgesia if needed
- Dexamethasone to reduce swelling and oedema
Definitive management:
- Urgent CT staging and biopsy to determine cause
- Stent the SVC
- Radiotherapy (if caused by non-small cell)
- Urgent chemo (if caused by small cell)
State some causes of hyponatraemia in lung cancer and how to manage acutely
Paraneoplastic syndromes:
- Cushing’s syndrome
- Hypertrophic pulmonary osteoarthropathy
- Lambert-Eaton syndrome
- SIADH
- Trousseau’s syndrome
Last less than 3 months :(
Management:
- Admit to hospital
- Fluid restriction
- Demeclocycline
- Tolvaptan
State some oncological emergencies in lung cancer
- MSCC
- Hypercalcaemia
- SVC obstruction / compression
State how to manage headache and brain mets
1) CT scan
2 ) Followed by MRI brain
- Start Dexamethosone 4mg bd
- Can give stereotactic radiosurgery (SRS) if < 5 brain mets
- If seizures, give Keppra
Shouldn’t be driving!!
State the pathway for someone presenting with suspected lung cancer from an abnormal CXR
- Triage by LC Physician - decide stage/investigations
- Urgent CT
- OPD appointment, see patient in clinic (LC Physician & Specialist Nurse) – Break Bad News, explain diagnostic plan
- Discuss at LC MDT – decision on treatment modality and update patient
- Patient seen by appropriate MDT specialist to commence treatment
State the time limits for a patient with suspected cancer
- No more than 62 days (2 months) from the date the hospital receives an urgent suspected cancer referral and the start of treatment
- No more than 31 days from the meeting at which you and your doctor agree the treatment plan and the start of treatment
State some types of lung cancer surgery
- Wedge resection (early disease and small tumour)
- Lobectomy
- Pneumonectomy
State the major subtypes of lung cancer
1) Small cell (rapidly progressive) = chemo-sensitive
2) Non-small cell:
- Squamous
- Lung adenocarcinoma (mutation driven, not associated with smoking)
- Large cell carcinoma (doesn’t respond well to chemotherapy)
State some characteristics of the major subtypes of cancer
1) Small cell
2) Non small cell
a) Squamous cell
b) Adenocarcinoma
c) Large cell
1) Small cell (20%)
- Arise from APUD cells
- Tend to cause paraneoplastic syndromes
- Tend to be more central
- Rapidly progressive
- But respond well to chemotherapy (not to surgery)
2) Non-small cell:
a) Squamous cell (35%)
- Arise from epithelial cells lining airways
- So tend to be more central
- Metastasise later than other types
- More likely to cause lung collapse or blockages
b) Adenocarcinoma (32%)
- Arise from peripheral, mucous secreting cells
- So tend to be more peripheral
- Less associated with smoking
c) Large cell (10%)
- Undifferentiated cancers and tend to lack structure of other 2 types
- Doesn’t respond well to chemotherapy
State some changes that could be seen on a chest x-ray in a patient with suspected lung cancer
- Visible mass
- Mediastinal widening
- Hilar lymphadenopathy
- Lobar collapse
- Pleural effusion
However none of the findings of diagnostic, requires histology and staging CT scan
State the 4 types of radiotherapy methods for lung cancer and when they are used
1) Radical - high dose with curative intent
2) SABR - focussed for smaller cancer with curative intent
3) Palliative - small dose for symptom control only
4) Intraluminal brachytherapy - if cancer is growing into central airways
State some palliative interventions for lung cancer
- YAG laser
- Cryotherapy
- Diathermy
- Brachytherapy
- Bronchial stents
State the NICE guidelines for lung cancer referral
> 40 with 2 or more of the following:
- Cough
- Fatigue
- SOB
- Chest pain
- Weight loss
- Appetite loss
If ever smoked - only need 1 of the above
Refer for a 2WW chest x-ray
State what pathway would the following scenarios cause
- >40 with haemoptysis
- CXR findings suggest lung cancer
2WW appointment to see chest physician
State the difference between EBUS, bronchoscopy alone and percutaneous CT-guided biopsy
EBUS - samples the lymph node (or multiple depending on results of PET-CT scan)
Bronchoscopy alone - samples cancer itself (cancer must be invading into bronchiole)
Use EBUS if there is lymph node involvement, if not need to do bronchoscopy alone
CT guided biopsy - samples cancer itself, especially for peripheral tumours (more invasive but good if further out)
State the risks and benefits of EBUS
State the risks and benefits of bronchoscopy alone (biopsy)
State the risks and benefits of percutaneous CT-guided biopsy
State 3 main subtypes of melanoma
1) Superficial spreading (70-80% of melanomas)
2) Nodular
3) Lentigo
Outline the 3 main subtypes of melanoma
1) Superficial spreading
2) Nodular
3) Lentigo
1) Superficial spreading (70-80% of melanomas)
- Relatively slow growing in early stages (should be readily detectable)
- Irregular in shape
- Irregular in colour
- Progressively changing
Also subtype of ‘spitzoid’ melanoma (which is ‘new’, ‘juicy’ and more regular in shape)
2) Nodular
- Faster growing
- Raised nodule
- Slightly or deeply pigmented
- Often friable / vascular
3) Lentigo
- Precursor of melanoma, in situ
- Very slow growth
- Associated with chronic sun exposure
Melanoma - state the following:
- Pathophysiology
- Location (where are they found on the body)
- Risk factors
- Presentation
- Investigation
- Management
Pathophysiology:
- Aggressive form of skin cancer, arising from abnormal melanocyte growth
- Presents as changes to / new pigmented lesions on the skin
Location (where are they found on the body)
Presentation - ABCDE:
Asymmetry
Border is irregular
Colour variation
Diameter >6mm
Evolution / elevation
Investigations:
- Excision biopsy
- Sentinel lymph node biopsy (if the Breslow thickness is >1mm)
- Further imaging e.g. PET CT if suspicion of mets
Management:
- Surgical excision (margin determined by Breslow thickness)
- Some additional treatments if needed e.g. radiotherapy, immunotherapy or BRAF inhibitors (do immunotherapy first then BRAF if positive)
State some risk factors for melanomas
- Family history or prior personal history of melanoma
- High levels of sun or UV exposure
- Fitzpatrick type I or II
- Immunosuppression
- Older age / male
- Smoking
Actinic (solar) keratoses - state the following:
- Pathophysiology
- Location (where are they found on the body)
- Risk factors
- Presentation
- Management
Pathophysiology:
- Dysplastic (precancerous condition)
- Lesions which are yellowish or erythematous, ill-defined, irregularly shaped, small, scaly macules or plaques
- Can potentially progress into squamous cell carcinoma (SCC)
Location:
- Occur at sun exposed sites e.g. head, ears
Risk factors:
- Fair skinned
- Outdoor occupation
- Older age
Presentation:
- Scaly rough patch, on erythematous background
- Feels like sandpaper
Management:
- Sun protection e.g. hats, sunscreen
- Cryotherapy (liquid nitrogen)
- 5-FU cream or Imiquimod
- Surgical excision / curettage and cauterisation
- Photodynamic therapy
Bowen’s disease - state the following:
- Pathophysiology
- Location (where are they found on the body)
- Risk factors
- Presentation
- Management
Pathophysiology:
- Also known as SCC in situ
- Dysplastic (precancerous condition) changes in the epidermis
- Non-itchy lesions, fixed, erythematous patches of skin
- Can potentially progress into squamous cell carcinoma (SCC)
Location:
- Commonly occur on lower legs of women
- Can occur on hands and nails
Risk factors:
- HPV
- Exposure to oils
- Fair skinned
- Outdoor occupation
- Older age
Presentation:
- Often multiple lesions
- Non-itchy, fixed, erythematous patches of skin
- Slightly scaly
- Don’t respond to moisturisers or topical steroids
Management:
- Sun protection e.g. hats, sunscreen
- 5-FU cream or Imiquimod
- Surgical excision / curettage and cauterisation
- Photodynamic therapy
Cryotherapy - less good as wounds take a long time to heal
Basal cell carcinoma - state the following:
- Pathophysiology
- Location (where are they found on the body)
- Risk factors
- Presentation
- Management
Pathophysiology:
- Most common non-melanoma skin cancer
- Malignant tumour of the keratinocytes within the epidermis
- Can be locally invasive, but very rarely metastasises (often in larger tumours)
- Common have multiple tumours - important to check whole of skin
- Associated with higher risk of other skin cancers (e.g. melanoma and SCC)
Location:
- Commonly sun-exposed areas of the face (commonly temples)
Risk factors:
- Fair skinned
- Childhood sunburn
- Family history
- Immunosuppressed
Presentation:
- Shiny, pearly nodule (sometimes a umbilical, necrotic or ulcerated center)
- Telangiectasia
- Appear translucent (don’t produce a lot of keratin)
Commonly can have multiple nodules
Management:
- Excise tumour (Moh’s micrographic surgery) if high risk e.g. near eyes, ill defined etc.
- Radiotherapy in poor surgical candidates
- Other options for smaller lesions e.g. curettage and cautery
Future = sun protection e.g. hats, sunscreen
Squamous cell carcinoma - state the following:
- Pathophysiology
- Location (where are they found on the body)
- Risk factors
- Presentation
- Management
Pathophysiology:
- 2nd most common non-melanoma skin cancer
- Locally invasive malignant tumour of epidermal keratinocytes
- Metastasis is uncommon (higher risk if large and poorly differentiated)
Location:
- Commonly sun-exposed areas of the face
Risk factors:
- Fair skinned
- Outdoor occupation
- Older age
- Sun exposure
- Chronic inflammation / actinic (solar) keratosis
- Immunosuppression
Presentation:
- Warty tumour (keratin) upon a fleshy base
- Can appear as ulcerated nodules if more advanced (poorer prognosis)
Management:
- Excise tumour if high risk e.g. near eyes, ill defined etc. (consider Moh’s surgery if recurrence of previous cancer)
- Radiotherapy in poor surgical candidates
- Other options for smaller lesions e.g. curettage and cautery
Future = sun protection e.g. hats, sunscreen
Outline the differences between a lesion of BCC and SCC
Both tend to appear on sun-exposed areas
Basal cell carcinomas:
- Shiny and pearly
- Don’t tend to be painful or bleed
- More slower growing
Squamous cell carcinomas:
- Irregular, ill-defined red nodule with scale and ulceration
- Can be painful or bleed
- More faster growing
Outline what Mohs micrographic surgery is and when it is used
Tissue is excised during surgery and examined under a microscope in real time
This is to ensure that all the cancerous cells are removed but the maximum amount of healthy tissue is preserved
This is done especially if :
- Area is ill-defined macroscopically
- Area is in need of preservation e.g. ear lobe or nose
State the general prognosis for squamous cell carcinoma
5 year survival of 99% (if detected early)
State how brain metastases secondary to melanoma can be managed
- Steroids (symptom management)
- Immunotherapy
- Surgery (less than 3 lesions)
- Stereotactic radiotherapy of surgery not an option (don’t tend to do whole brain radiotherapy)
Outline common sites of metastasis for lung cancer
LBBA
Liver
Brain
Bone
Adrenal glands
+ lymph nodes
Outline common sites of metastasis for melanoma
LLBB
Lung
Liver
Brain
Bone
+ lymph nodes
List some causes of pneumonitis in patients undergoing lung cancer treatment
- Radiation
- Immunotherapy / targeted therapies
- Chemotherapy e.g. Bleomycin, Methotrexate
- Tumour itself
Outline the presenting symptoms and signs of pneumonitis
- Dyspnoea
- Chest pain (pleuritic)
- Cough
- Low-grade fever
- Reduced O2 sats
What investigations are useful in diagnosing pneumonitis and results would it show?
Chest x-ray:
- Airspace opacities
- Pleural effusions
- Atelectasis
Non contrast HRCT:
- Ground-glass opacities
- Airspace consolidation
Bronchoscopy
How is pneumonitis managed in lung cancer treatment?
- Consider pausing / halting treatment therapy e.g. immunotherapy
- Steroids e.g. IV Methylpred then oral Prednisolone (reduce inflammation)
- Ventilation / ITU may be required if severe pneumonitis
- Consider antibiotics if suspicion of infection
